Gestational Carrier Initial Intake Form | The Surrogacy Collective

First Name

Preferred Name

Last Name

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Phone Number

Best time to call

May we leave a voicemail at this number?

Email Address

Preferred Method of Communication from us, the agency.

Please specify "Other".
Example: Social Media Handle, WeChat ID, Skype ID etc.

Country

Street Address

City

State

Zip Code

Current Height

'

"

Current Weight

lbs

Are you a member of a Native American tribe?

Please provide details

What language do you speak?

Are you a Legal US Citizen?
If you have a green card, permanent residency, TPS or other legal immigration status please list it under "Other" and list what status you have.

Other

What country do you retain citizenship?

Are you receiving any forms of government financial assistance?

Have you used nicotine products, smoked, or vaped during a previous pregnancy?

Do you use nicotine products, smoke, or vape?

Are you willing to quit?

Have you ever received a diagnosis of bipolar disorder from a medical professional?

Have you ever been diagnosed with any other mental health disorder(s) by a medical professional?

Please explain diagnosis, date of diagnosis and whether the issue is ongoing or resolved

Have you been diagnosed with gestational diabetes, requiring the use of insulin to control the condition?

Please provide details.

Have you had any felonies or drug-related convictions in the past 10 years, or any convictions for violence or sexual abuse?

Please provide details

Are you currently on probation or parole?

Please provide details

Have you undergone uterine ablation?

Please provide details

Has your spouse/partner had any history of convictions for domestic abuse, sexual abuse of any sort, acts of violence, or is currently on probation or parole stemming from a criminal offense?

Please provide details

Where did you hear about us?

Social Media

Personal Referral

Clinic Referral

Other

Referral Name

Clinic Name

Other